Observations:
Based on review of facility policy and procedures and interview with staff (EMP), it was determined the facility failed to maintain documentation of completion of daily cleaning procedures for the Crisis Response Center (CRC) at the Episcopal Campus.
Findings include:
Review on April 28, 2025, of facility policy "Cleaning Procedures," reviewed May 21, 2024,
revealed, " ... BEHAVIORAL HEALTH (Episcopal Campus) ... Daily Cleaning Procedure Empty trash, clean containers, replace liners (paper only, no plastic), Damp wipe horizontal surfaces, high dust, Spot clean walls, Clean mirrors, sinks water fountains, polish furniture, Clean bathrooms, replenish supplies, Dust mop, damp mop." Further review of the policy revealed it did not contain maintaining a documentation log of completion of the daily cleaning procedures.
On April 15, 2025, at 10:37 AM, surveyor requested EMP1 for documentation of cleaning logs for the CRC.
Email interview with EMP1 on April 28, 2025, at 2:02 PM, confirmed there was no documentation logs for the completion of the daily cleaning procedures for the CRC at the Episcopal Campus.
| | Plan of Correction - To be completed: 07/31/2025
The Associate Vice President of Health System Logistics, who is the leader for Environmental Services at Temple University Hospital Inc. (TUH), has ultimate responsibility for the implementation and monitoring of the action plan.
Policy TUH Inc.-EVS- 950.1403 Cleaning Procedures was reviewed, and no changes were recommended.
Cleaning of the Crisis Response Center (CRC) at the Episcopal campus is noted in a daily log and assignment sheet. The completed log for the day in question was missing. As a result of this complaint investigation and related citation the existing log was modified 5/28/2025 to include a signature for the employee completing the work and the manager/supervisor who will review the work. This revised log will be implemented effective 5/30/2025.
All staff will be educated on their cleaning responsibilities and completion of the revised log to include signatures by the manager/supervisor in person when receiving their assignment for the shift. All staff education will be completed by June 14, 2025.
The director of Environmental Services (EVS) will audit compliance with completed signed logs daily starting June 15, 2025. Each daily log will be reviewed for both signatures until July 15,2025. Any logs noted to be missing signatures will be remediated in real time by the manager/supervisor.
Compliance is anticipated to be 100%. After 30 days of 100% compliance, audits will decrease to weekly and will continue one day a week varying days of the week for the duration of the plan of correction: July 31, 2025.
Sustainability is identified through the results of monitoring or auditing for the data elements below. When the results do not meet the benchmark, additional actions are implemented using the plan-do-study-act (PDSA) performance improvement process. Results are re-monitored or re-audited. Remediation with individuals is conducted when an issue is identified.
The results of this auditing plan will be presented at TUH Inc. Patient Safety Committee in June 2025. The plan of correction and related auditing results will also be disseminated to the Medical Staff Executive Committee and the Professional Affairs Committee of the Board of Governors in June and July 2025.
The Executive Sponsor will make a recommendation as to Monitoring and Sustainability at the end of the Action Plan July 31, 2025. This recommendation will be brought to the TUH Inc. Patient Safety Committee for approval in August 2025.
All education, sign-off sheets, audit results, Committee and Board minutes, and other pertinent documents are maintained and available upon request for review by the surveyors.
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